Healthcare Provider Details

I. General information

NPI: 1043414022
Provider Name (Legal Business Name): DCCCA, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/13/2007
Last Update Date: 05/29/2020
Certification Date: 05/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12351 W 96TH TER SUITE 300
LENEXA KS
66215-4409
US

IV. Provider business mailing address

3312 CLINTON PKWY
LAWRENCE KS
66047-3624
US

V. Phone/Fax

Practice location:
  • Phone: 913-894-0900
  • Fax: 913-894-0908
Mailing address:
  • Phone: 913-894-0900
  • Fax: 913-894-0908

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number StateKS
# 2
Primary TaxonomyY
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number00590942
License Number StateKS

VIII. Authorized Official

Name: KERYE J. JACKSON
Title or Position: CFO
Credential: CPA, CMA
Phone: 785-841-4138